Request For Payment Of Substitute Teacher

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REQUEST FOR PAYMENT OF SUBSTITUTE TEACHER
Before a check will be issued the following must be on file in the Payroll Office: Forms W-4, K-4 (or IT-4), I-9,
Copy of Social Security Card, Acceptance Form regarding Sexual Misconduct Policies
SCHOOL
SUBSTITUTE TEACHER
REGULAR TEACHER
NAME ___________________________________
NAME ___________________________________
(no nicknames please)
SS#_________/________/__________
FILE# __________________
No. of days payment is due Substitute ________
Work Absence of Regular Teacher to be Charged to:
(Check One):
: ____/____/____, ____/____/____
Dates
____
Leave Per Contract ( Illness, Maternity, Bereavement)
____Absence with pay for Professional reasons,
____/____/____, ____/____/____
approved by administrator (including internship).
____Absence for jury duty (see Policy P4580)
____/____/____, ____/____/____
____Leave without pay.
____ Other :
____/____/____, ____/____/____
____/____/____, ____/____/____
Total deduction from Annual Leave ______days.
Pay rate
for consecutive days worked for the same
teacher (check one of the following):
_____ 1-10 days = $75 per day
APPROVED BY:
_____ 11-20 days = $90 per day
_____ 21-30 days = $115 per day
_____ Over 30 days = full scale *
*If scale: Certification Rank
_________
Local Administrator's Signature
Date
Allowable Yrs Exper
_________
Note: If Substitute is due pay at mixed pay rates
use a separate form for each rate,
For Payroll Dept. Use:
Comments:
Gross Paid $____________
Date _______
Total Charge/Credit $____________
(Gross plus 7.65% FICA)
Please make 2 additional copies of this form:
Original - Payroll Office
Copy - Substitute Teacher
Copy - School

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